A targeted approach for routine viral load monitoring in Malawian adults on antiretroviral therapy

Trop Med Int Health. 2018 May;23(5):526-532. doi: 10.1111/tmi.13047. Epub 2018 Mar 30.


Objectives: WHO recommends HIV viral load (VL) testing 6 months after antiretroviral therapy (ART) initiation and every 12 months thereafter, but cost prohibits routine, universal VL testing in many developing countries. We sought to devise a targeted approach to routine VL monitoring that could reduce cost and identify those at low risk for virologic failure (VF).

Methods: We analysed screening data from a clinical trial enrolling adults on ART in Malawi. We identified risk factors associated with VF and employed the Knill-Jones method to assign summary score identifying persons at lower risk for VF.

Results: Among 957 adults, prevalence of VF was 9.4%. Factors independently associated with VF included age <38 years (OR 3.44, 95% CI 2.01-5.89), ART duration >2.5 years (OR 2.98, 95% CI 1.79-4.96), ART adherence <95% (OR 1.76, 95% CI 1.06-2.94), CD4 count <200 cells/μl (OR 5.94, 95% CI 3.27-10.78), haemoglobin <13 g/dl (OR 2.76, 95% CI 1.70-4.50) and CD8 count >885 cells/μl (OR 2.10, 95% CI 1.28-3.44). Our VF prediction summary score included all factors above except CD8 count and was fairly accurate with validated area under receiver operating characteristic curve of 0.76. Implementation could reduce VL testing by 65%.

Conclusion: A simple score incorporating age, ART duration and adherence, and CD4 count can accurately identify adults at low risk for VF in a sub-Saharan African setting. In areas with high ART utilisation and limited VL testing capacity, a targeted approach could optimise routine VL monitoring while identifying adults in need of alternate ART regimens.

Keywords: HIV; Malawi; VIH; antiretroviral therapy; surveillance de la charge virale; traitement antirétroviral; viral load monitoring; virologic failure; échec virologique.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Anti-HIV Agents / therapeutic use*
  • Antiretroviral Therapy, Highly Active
  • CD4 Lymphocyte Count
  • Diagnostic Tests, Routine / economics
  • Diagnostic Tests, Routine / statistics & numerical data*
  • Female
  • HIV Infections / drug therapy*
  • Humans
  • Malawi
  • Male
  • Medication Adherence / statistics & numerical data*
  • Middle Aged
  • Viral Load*
  • Young Adult


  • Anti-HIV Agents